Provider Demographics
NPI:1649220054
Name:OTTAVI, THOMAS MICHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:MICHAEL
Last Name:OTTAVI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 ASSOCIATES DR
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52002-2201
Mailing Address - Country:US
Mailing Address - Phone:563-584-4100
Mailing Address - Fax:563-584-4110
Practice Address - Street 1:200 MERCY DR
Practice Address - Street 2:SUITE 201
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001-7303
Practice Address - Country:US
Practice Address - Phone:563-584-3500
Practice Address - Fax:563-584-3520
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00837103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI10660Medicare ID - Type Unspecified
IA35817OtherWELLMARK BC/BS